Hypothyroidism Manifesting as a Combination of Ascites and Malnutrition Requiring Total Parenteral Nutrition: A Unique Presentation

Ascites is the abnormal buildup of fluid in the abdomen. Despite appropriate workup, including diagnostic paracentesis with fluid analysis and abdominal imaging, the cause of ascites is sometimes unknown. In this case, testing for less common causes should be performed, including checking thyroid function test (TFT) because hypothyroidism has also been reported to be a rare cause of ascites. Patients may also have concomitant malnutrition as an effect of severe hypothyroidism, rather than as its cause. We report the case of a 62-year-old female with a history of hypothyroidism and non-compliance who presented with unexplained ascites and then also developed severe malnutrition, requiring total parenteral nutrition (TPN). Extensive testing, including laparotomy, was unable to reveal the cause of ascites and malnutrition until the patient mentioned, during her hospital stay, non-compliance with her home dose of levothyroxine (175 μg) because of the cost. TFT results indicated that the patient had severe hypothyroidism, with a thyroid-stimulating hormone (TSH) level of 21.9 IU/mL and a free thyroxine level (T4) level of 0.2 IU/mL. The patient’s home levothyroxine dose was resumed. The patient clinically improved and was discharged on an oral diet. The patient’s ascites resolved completely, the TSH level was 2.39 IU/mL, and the T4 level was 1.7 IU/mL at the eight-week follow-up.